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Laser Liposuction & Skin Tightening - Emperor's New Clothes?

Laser Assisted Liposuction - Medical Spa MDDoes laser assisted liposuction really provide all of the skin tightening benefits that the manufacturers claim?

We are in pursuit of many Holy Grails in plastic surgery, from scarless post-surgical healing, non-invasive liposuction and implant-free breast augmentation to non-invasive skin tightening. With the advent of laser-assisted liposuction (LAL) came the promise from the manufacturers that we have finally achieved a way of combining "minimally invasive" fat removal with skin tightening, sensationally treating two maladies with one procedure.

I been involved with LAL for many years, and it has been the primary revenue driver in my practice for nearly five years running. I began to perform the procedure when the machines became powerful enough to actually generate enough subdermal heat in a timely fashion to potentially create significant collagen remodeling and hopefully result in skin tightening. My case load quickly became large enough that I was asked to be a national speaker for one of the dominant laser companies educating other physicians on the use of LAL. As such, I delved into every published paper even remotely relating to heat-generated skin tightening and laser assisted liposuction. Over the years, I have been able to merge a huge surgical experience with the science behind the procedure and draw some fairly clear and simple conclusions on the issue of skin tightening.

Setting up a patient for potential skin tightening is fully dependent on generating ample subdermal heat to initiate collagen denaturation and subsequent remodelling. Generally, this temperature is felt to be between 40 to 45 degrees celsius.  At around 47 degrees celsius, skin blistering and burns occur.  With proper time, temperature-monitoring devices, and careful technique, adequate temperatures can be achieved. Getting the skin to this temperature range takes time and significantly prolongs the procedure. Additionally, the risk of seroma escalates the longer you spend with the tissues in this temperature range in my experience.

In about 15% of cases, I see clinically visible skin tightening which I don't feel I would have seen using other techniques. This skin tightening is not the equivalent of excision techniques, but typically limited and subtle. This is obviously purely my subjective opinion to be clear, and I cannot say that these same results may not have occured witht the same frequency had I used other liposuction techniques.

The science of LAL and skin tightening is clear that some tightening does occur and is quantifiable. But this does not predictably translate into clinical relevance. I have now performed nearly 1000 LAL's and no longer educate my patients that LAL is a good method of tightening skin. The limited degree of tightening I credit LAL for is not enough to call it a clinically relevant skin tightening procedure. The majority of new LAL consults in my practice present with the impression that LAL is going to tighten up their loose skin while removing fat. The notion is dominant on the internet and even in print ads. I politely educate them that although there may indeed by some skin tightening, this will be subtle at best. In my opinion, the advantages of LAL lie elsewhere, particularly in a somewhat easier recovery.

I continue to hear from colleagues who also use LAL that they believe in the skin tightening.  I don't know if this is a case of "The Emporers New Clothes" or not. I have pushed the envelope in terms of thoroughly heating up the skin to appropriate temperatures and length of time, but only see minimal tightening and an increase number of seromas. I continue to use LAL heavily but no longer tout skin tightening as being an expected end point.

Reader Comments (7)

Excellent post Dr. Howard! There's a long history of the manufactures exaggerating benefits and it's understandable that in any practice that is elective, that if you're falling of of the fence it will be on the side that accrues the most benefits. It's through excellent information like this post that we all learn what is really going on in order to make more informed decisions; whether it's which tech to buy, or how to educate patients in a consult.

Dr. Howard: good for you for admitting the inconvenient truth about laser-assisted liposuction. It's driven by the manufacturers and their direct-to-patient marketing, and the science to back up their claims is, shall we say, limited at best. While there may be some slight skin tightening effects that one can measure, it is slight, and the laser-assisted lipo doesn't provide the magnitude of tightening that patients want to see. In the worst cases, the complications caused by the thermal injuries are hard / impossible to fix. Primum non nocere.

Excellent artiicle, Dr. Howard. As a laser practitioner, I can agree that clients everywhere are looking for the magic treatment that will tighten loose skin (short of plastic surgery).

I can add that while we cannot "tighten" skin we have been quite successful using a LED device to rejuvenate collagen, fibroblasts and elastin in aged skin. By using this LLLT method, we have been able to reduce wrinkles by stimulating angiogenesis as well as jump starting the dermis to reproduce collagen and enhance the underlying skin structure in a safe, low light treatment. We use a Revitalight red light focusing on a series of approximately 6, 20 minute sessions spaced 2 weeks apart. We have seen remarkable, visible improvement with the most noticeable results coming from our oldest clients. This treatment reduces wrinkles by stimulating collagen which "inflates" the skin beneath the wrinkles therefore producing a smoother, more robust fill under the epidermis. The beauty of LED is that it is so safe and carries no risk of thermal burn or injury.

And, using the ND:Yag laser at approximately 50-54 joules with a 3ms pulse width, I have been able to tighten facial muscles to effect a visible "lift" in sagging facial muscles including the nasal/labial fold as well as downturned corners of the lips. Because the treatment is in office, pricing is relatively inexpensive and safe.

Skin tightening and dermal remodeling seem to remain in the surgical domain for the time being. I have purchased lightbased equipment with the promise that it would remove stretch marks, cellulite and all the other demons of aging. Lots of money is being wasted on this equipment. Hopefully, though, some manufacturer of a light based device will find the magic model and protocol that will allow us to help people non-surgically.

I really appreciate your input and honesty.

Marti Settle

Very good article. Thanks! The example of LAL amplifies the common problem in this industry: claims that are based more on common wishes than reproducible evidence. From injectables to stem cells... hypes that bring quick, but short-lived, fame and money.
Most of those companies thrive on impressing the newest adepts of Aesthetic Medicine and those who may not have an in-depth knowledge of physiology, anatomy and pathology. It is very easy to be impressed and suppress own critical awareness by the "before and after" photos and ROI baits.
Yes, there are some technologies that work very well but many simply forget that the best results are operator dependent. It is common, but foolish, to buy a new device, designate someone to do the treatments according the protocols and expect superior outcomes. And, as we've seen in several discussions on this website, some "reputable" manufacturers will not even provide you with sensible protocols. Again, they are greatly responsive to you until you buy their equipment. All too often you are on your own.
The MedicalSpaMD, to my knowledge, is the only relevant website that can be of enormous help to the Aesthetic community if one is able to spot the evident self-serving entries. I hope, one day, this site will have enough visibility to reach popular media... as an unbiased(?) voice of aesthetic reason and patient advocate; as an alternative to celebrity hypes and spectacular endorsements by "luminaries".

Another secret the reps don't divulge is that the technology rapidly changes-the laser you purchased (which hasn't been fully paid yet) will be prehistoric in the next 6-12 months.

06.20 | Unregistered Commenterjerry

The "new" lasers have to disclose the wavelenghts they function at. If you compare the technical info of one with the other you will see if there is a significant difference to warrant making another purchase.

06.21 | Unregistered Commenterlefty2g

One of my chapters in my book, "Behind the Mask, Beneath the Glitter: The Deeper Truths About Safe, Smart Cosmetic Surgery", discussed the hype in cosmetic surgery technology: 'Hype, Hype... Hooray!'. Usually the companies talk about the percent increase in shrinkage compared to control groups. Thus if there is a "increase in shrinkage" from 10% to 15% shrinkage, it is referred to as a 50% increase. In reality, one only has to think of what happened to skin grafts. There is a natural "shrinkage" when split thickness graft is harvested due to intrinsic elasticity. Yet when we don't want a graft to shrink (i.e. contract), we harvest a full thickness graft which also has a slight but diminished intrinsic tendency to shrink. In short, I never bought into, nor bought, the technology that claimed increased skin tightening because I suspected that most of the skin tightening had to do with intrinsic elasticity that is differentially released (probably due to dissection closer to the dermis, and that the modest "increase" in "tightening" either did not exist or was not predictably obtained in significant magnitude to justified the obvious increase in risk. However, it is a great sales tool...

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